How obstetricians and pregnant women decide mode of birth in light of a recent regulation in Brazil

Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review

Importance

Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.

Objectives

To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.

Evidence Review

We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.

Findings

Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.

Conclusions and Relevance

This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

Agreement between antenatal gestational age by ultrasound and clinical records at birth: A prospective cohort in the Brazilian Amazon

This study aimed to assess agreement between antenatal estimates of gestational age by ultrasound and clinical records at birth in the Brazilian Amazon. Ultrasound examinations were scheduled during the second trimester for 578 pregnant women prospectively screened at primary health care units, following a standardized protocol for image quality control. A multistage algorithm was used to assess the best estimate of gestational age during the antenatal period, considering reliability of last menstrual period (LMP) and acceptable differences in relation to ultrasound estimates derived from fetal biparietal diameter and femur length. Agreement of antenatal estimates of gestational age confirmed by ultrasound and clinical records at birth was analyzed with Bland-Altman plots and kappa coefficients (preterm and postterm births). Overall, ultrasound examinations presented high quality (>90% of satisfactory images), and were adopted as the best estimate of gestational age among 83.4% of pregnant women, confirming reliable LMP in the remaining proportion. On average, difference in gestational age between antenatal estimates and clinical records was 0.43 week (95% CI: 0.32, 0.53). Classification of preterm births had a good agreement (kappa: 0.82, p<0.001), but a poor performance was observed for postterm births (kappa: -0.06, p = 0.92). Higher differences in gestational age were noted for participants with >11 years of education and cases of caesarean deliveries. In conclusion, high-quality ultrasound images from the second trimester of pregnancy based the assessment of gestational age, while reliability of LMP was limited. Information from clinical records at birth presented an acceptable agreement on average and for classification of preterm births, which is relevant for properly interpreting perinatal outcomes. Discrepancies in caesarean deliveries may warrant further investigation.